The arthroscopic approach to lateral epicondylitis: The literature jury is still out

Lateral epicondylitis, or tennis elbow, is an amazing entity and for us to have so few ideas on what actually causes the pain is truly a confounding variable in terms of the treatment of upper extremity problems. These people are sometimes in so much pain that outcomes scores sometimes show higher disability scores than you see with a supracondylar humerus fracture. It makes you wonder what it is that is hurting so much.

You really don’t see a lot of inflammatory cells when you look at the biopsy specimen and you spend a lot of work looking into the histochemistry and so forth that may promote some of the feeling of inflammation without a lot of inflammatory cells. But clearly these patients hurt a tremendous amount.

Nonoperative measures to treat this are as multiple as they can possibly be. If you look at the results being about a 90% resolution at 1 year and that includes handing the patient a pamphlet and saying that you have tennis elbow come back and see me in a year.

Multiple operative treatments

There are more than 40 options for operative treatment. Probably one of the best articles has been written by Boyer and Hastings in the Journal of Shoulder and Elbow Surgery and they really have great reviews about the operative management of this condition. However, they note, “There is much witchcraft and pseudoscience involved in this treatment.” Clearly there is and so we set out, to some degree, to debunk some of the witchcraft and wizardry.

David S. Ruch

Champ Baker, MD, a forward-thinking guy, looked at arthroscopically resecting the extensor origin from the articular aspect rather than making incisions; just doing it from the outside. In a published article they reported on 42 cases using his technique. In his series, he looked at comparing open to arthroscopic and they showed superior results with the arthroscopic technique including a 2.5 week return to work for white collar and blue collar workers.

I can’t even get my patients to get back to work at 9 weeks, let alone 2.5 weeks I think the results were really intriguing and also showed that there were some associated articular pathologies, a rupture to the capsule, some plica, loose bodies in several and some had evidence of instability.

Our series

We decided to look and see whether or not this was humanly possible. Adam Smith, who is our resident, went back and looked at cadaver elbows to look for feasibility of an arthroscopic resection. He dissected out the musculotendinous junction on the lateral aspect, inserted needles and saw where they came into the articular aspect. He identified the location of the various tendinous origins of the common extensor including extensor digitorum communis (EDC) and extensor carpi ulnaris (ECU). Then he determined how much of the tendons were released once you’ve done the arthroscopic procedure. He found that you can get about 100% of the extensor carpi radialis brevis (ECRB) involved. So clearly, it is feasible to do this from an arthroscopic approach. You get about 80% of EDC; we did not get that in the ECU patients.

A key point for the arthroscopic approach: When you look across the proximal medial portal, it is useful to take the radial head and bisect it. You really don’t want to release it and it to go back into this bisection viewpoint. If you did, you’re going to get a gap here at the radial capitellar joint which can lead to posterolateral rotary instability if your arthroscopic resection is too far posterior.

Which is better?

Really, which was better, open in our hands or arthroscopic? We tried to do a more tightly controlled study than Baker’s. We looked at 40 patients; using a shaver inserted low in radial carpal joints so that you can angle it up in order to get to the common extensor origin. We did not treat any of the associated other pathologies we saw with these patients.

Looking at some retrospective analysis of patients who received open, endoscopic and anconeus flap treatments and were followed between 6 weeks, 12 weeks, 6 months and 1 year. We found that the DASH scores for the anconeus flap group improved better than in either of the other groups. It was shocking for me because I only used the anconeus flap for those patients who had revisions and many of these had substantial soft tissue defects over the common extensor. I think it does have a role in the management of lateral epicondylitis maybe beyond that for only revisions.

Posterolateral plica

The arthroscopic approach can be useful in atypical-type of presentations that are frequently seen in golfers, volleyball players, and certain collage athletes. With these, pain is more with terminal extension and supination. These patients are frequently treated for quite a long time for lateral epicondylitis and their symptoms are reminiscent of posterolateral rotatory instability, yet they have no history of trauma.

In this patient population arthroscopy reveals in the posterior radial capitellar joint a large floppy band of what some people might call a plica; some might even refer to it as a partial evulsion of the lateral complex. This is what is pinching as the patient as he or she is coming into terminal extension and supination. This structure has shown to be innervated and vascularized. You can use anything you want to get rid of it. I tighten the structure up just a little bit with thermal shrinkage and then I place these patients in a splint for about 3 weeks to try and make that a little bit tighter. In our hands, these patients did nicely with this particular technique.

So, when do I really offer arthroscopic approach to these patients? The majority of these patients frequently come in with this preconceived notion that they want to most minimally invasive procedure done. Many of them are high-caliber athletes. Maybe the assumption that if it’s done endoscopically in a variety of possible fashions then they are going to get more functional outcomes. I think much of this is patient driven, but from an objective data collection standpoint, I don’t see any difference in any of the literature, or in my own series.

For more information:

• David S. Ruch, MD, head of section of hand surgery, department of orthopedics, Duke University, can be reached at DUMC 3466, Durham, NC 27710; 919-613-7797; e-mail: d.ruch@duke.edu. He has no direct financial interest in any products or companies mentioned in this article.

References:

• Baker Jr CL, Murphy KP, Gottlob CA, et al. Arthroscopic classification and treatment of lateral epicondylitis: two-year clinical results. J Shoulder Elbow Surg. 2009(6):475-482.
• Boyer MI, Hastings II H. Lateral tennis elbow: “Is there any science out there? J Shoulder Elbow Surg. 1999;8(5):481-491.
• Ruch DS. Lateral epicondylitis surgery – Open. Precourse 9. Presented at the 63rd Annual Meeting of the American Society for Surgery of the Hand. Sept. 18-20, 2008. Chicago.